Last days to send the Survey Visiting hours and comfortability of the Spanish ICUs

Hola a tod@s my dear friends:

Dr. Dolores Escudero head of the ICU of Hospital Universitario Central de Asturias and one of the member of the Research Team IC-HU Project, wants to remember us this survey directed to ICUs of Spain about visit politics and comfortability.

  • Learn about the Spanish ICU visit politics
  • Meet the organizational and architectural generals aspects of the Spanish ICUs, in order to assess their level of comfort
To complete the survey click here, complete the form takes less than 5 minutes.
Last day to fill it, 22 of September!

Thank you very much for your cooperation.
Contact: Lorena Martín Iglesias (

Happy Thursday

Tox on the Web: sarin, lithium, strychnine, and much more!


Toxicologist as Man on Couch with Laptop: This video shows a short presentation by Larissa Laskowski a first year fellow at the NYC Poison Control Center, describing the work of Eliot Higgins and the Brown Moses blog. Higgins — an unemployed finance worker several years ago with no knowledge about weapons of warfare — started blogging about the use of different weapons in Syria, and posting online videos appearing on sites such as YouTube that demonstrated use of these weapons. He is now an acknowledge expert in the field. His work led to the identification of sarin as the agent used in the Ghouta chemical attack on August 21, 2013. Dr. Laskowski ends by challenging toxicologists to make use of their knowledge to effect positive change in the outside world. Inspiring stuff. For more on Higgins and Brown Moses, read this story in the Guardian (U.K.). [HT @acmt]

Would you like some lithium with that? In a New York Times opinion piece, psychiatrist Anna Fels reviews the evidence suggesting that we’d all be better off if a little lithium were added to our water, soda, and beer.

All white powders look alike: The Los Angeles Times reports that a 14-year-old boy in the town of Anderson may be charged after he allegedly gave a white powder to another youth, say it was cocaine. The other youth died after snorting the powder. Subsequent analysis revealed that it was actually strychnine.

Must-read: Lake Erie and the Toxic Bloom: In a long story that’s both extremely informative and amazingly well-written, Dan Egan of the Milwaukee Journal Sentinel explains how the “toxic algae cocktail brew” that poisoned and shut town the Toledo OH water system last year was possibly the harbinger of much worse to come. BTW, it’s become ever clearer that the J-S is one of the best papers in the country when it comes to coverage of science, medicine and the environment. (HT @deborahblum)

Murder by nicotine? People Magazine has a brief update on the case of nuclear engineer Paul Curry, who is on trial in Santa Ana, CA charged with killing his wife Linda 20 years ago by injecting her with nicotine. Prosecution expert Dr. Neal Benowitz testified that he had “never seen levels like this in any blood sample.” Curry’s public defender argued that the nicotine might have been present because his wife may have been using it to treat irritable bowel syndrome.

The discovery of LSD: The Atlantic Magazine has an excerpt from Tom Shroder’s new book Acid Test: LSD, Ecstasy, and the Power to Heal. The piece describes the accidental discovery of LSD by chemist Albert Hofmann in April 1943. Shroder quotes Hofmann’s own description of the experience:

The dizziness and sensation of fainting became so strong at times that I could no longer hold myself erect, and had to lie down on a sofa … Everything in the room spun around, and the familiar objects and pieces of furniture assumed grotesque, threatening forms. They were in continuous motion, animated, as if driven by an inner relentlessness. The lady next door, whom I scarcely recognized, brought me milk—in the course of the evening I drank more than two liters. She was no longer Mrs. R, but rather a malevolent, insidious witch with a colored mask … Every exertion of my will, every attempt to put an end to the disintegration of the outer world and the dissolution of my ego, seemed to be a wasted effort. A demon had invaded me, had taken possession of my body, mind, and soul … I was seized by the dreadful fear of going insane. I was taken to another world, another place, another time. My body seemed to be without sensation, lifeless, strange. Was I dying?

The excerpt made me want to read the entire book.

FOAMed – a Primer for Physicians

So this week I am giving a talk to a bunch of physicians at the Internal Medicine Society of Australia & New Zealand. In true FOAMed spirit, I’m making the talk available online prior to the session (as a nod to the concept of a ‘flipped classroom’) and putting up some useful links for those who decide to explore the FOAMed world a little closer.

Big thanks to Chris Nickson for the inspiration of using Star Wars stormtroopers as a metaphor for ‘taking the world by storm’…and of course to Joe Lex for both the oft-quoted phrase “if you want to know how we practiced medicine…” as well as introducing me to the terms of pedagogy, andragogy and heutagogy.

They say that an audience will only take away THREE things from any talk. The concepts I wanted to get across were :

  • half of what we learn is wrong; FOAMed is a tool to help narrow the knowledge translation gap and keep up-to-date
  • we live in an age of information overload, likened to ‘drinking from a firehose’. Social Media tools allow filters to help drill down to the information that is relevant to your needs
  • using the tools of FOAMed and social media, we can make a commitment to lifelong learning much easier. Moreover, with such accelerated learning comes the potential for metacognition – specifically to understand HOW we learn and make decisions as clinicians. This is important as our diagnostic acumen is subject to bias and may fool us, regardless of our knowledge base.

So, here’s the talk as a narrated slideshow hosted on vimeo :

The slides can be downloaded by clicking HERE

The introductory video (FOAMed – taking the world by storm) is below :

What is FOAMed and why should I use it?

I like to think of FOAMed as a global sharing of information. We are all involved in clinical educators  we get up at journal clubs, grand rounds or conferences and deliver talks. But the reach of those talks is confined to those who attend…unless you take the bold step of creating online content – basically, putting up your ideas, talks, slides etc online in a form where ANYONE can access them. This might be in the form of a blog (reading commentary or analysis), a podcast (eg : listening to a discussion on a contentious topic) or a video (watching how to perform a procedure).

Good FOAMed sites collate information, curate it and disseminate it – with information made available for free (although attribution is expected).

It is hard to go beyond the summary of FOAMed origins and uses from the crew

Chris Nickson talks about “Why FOAMed – facts fallacies and foibles”

Andy Neill’s pecha kucha talk is here “Effective Use of Social Media to Keep Up-to-Date

Richard Body talks on why FOAMed is essential for emergency clinicians (from #CEMExeter14 conference)

David Marcus has a great set of slides here : FOAMed primer and other talks at EM IM blog


Some great examples of collated & curated FOAMed sites include : &

and so on…

There are MANY MANY more – mostly emergency and critical care, but increasingly other specialties are coming on line – urologists (eg uroJC twitter journal club), general practitioners ( etc.

The best medical conference – ever!

For a good example of how an excellent medical conference should be run, it’s hard to top smacc. Cadogan commented that whilst FOAMed was conceived in a Dublin bar in 2012, FOAMed was conceived at smacc2013 in Sydney. A year later smaccGOLD built on that success, with many different ‘tribes’ involved in critical care and emergency medicine coming together to share stories and learn from each other. Next year we are off to Chicago for smaccUS…check it out & register at

There is also an iTunes feed for downloadable podcasts -

Of course the collated videos of smacc talks are available on Vimeo via

Here’s some feedback on smacc from assorted bloggers

“Lessons learned from smacc – bye bye dogma, – hello best practice”

“You’ve gotta have love”

“Social media & critical care”

“smaccGOLD – it hurts”

“Where do you start with something like smacc?”


How to use tools of Social Media to help filter and signpost FOAMed

Social media (SoMe) is useful to disseminate and discuss clinical topics. By now you will be aware that there is a vast repository of useful educational resources “out there” on the net – blogs, podcast, videos etc. But how to filter them?

The easiest thing to do is just to read blogs on topics you are interested in or authored by people who you feel have something to offer. One of the nice things about the FOAMed community is that people share good content willingly and will signpost links to interesting content. Good sites collate quality FOAMed material, curate it and disseminate it. They may have a ‘search’ function on the site…failing that, there is always to search for good stuff.

Screen Shot 2014-09-16 at 11.37.05 am

RSS feeds are ideal – if you see this symbol on a website, click it to ensure that new content is delivered to your email, RSS aggregator or iTunes download queue. This makes it much easier to target FOAMed content that you are interested in – rather than have to trawl through blogs looking for updates, new content is streamed to you. By only clicking on feeds that are of interest to you, one can filter the FOAMed content, to a degree.



I am a big fan of using RSS aggregators to collate input from twitter, blogs, google+ etc into an app – I use one called Feedly, which displays my content in a magazine style format


Twitter. Really?

I was a sceptic initially, but now find that twitter is a great way to keep in touch, ask questions of colleagues, discuss concepts and also signpost relevant journal articles or FOAMed resources.

Twitter is essentially a microblogging platform – once you’ve registered, set up a user ID and a brief description of self/interests, then you are free to either follow like-minded people or start opening up your own conversations. Tweets are limited to 140 characters, so it is very difficult to have a nuanced conversation, Hashtags are common for conferences eg #IMSANZ14 and can also be used to collate information eg : #FOAMed #resus would delineate tweets with these items as search terms.

The Twitter app is free for download on mobile and PC/OS platforms. Afficiandos may decide to use an app like TweetDeck or TweetBot to allow collation of different content and even schedule tweets (I was involved in an on stage debate at #smaccGOLD on the use of checklists in airway management, and managed to wow the audience by talking and having simultaneous twitter feed broadcast to the audience both in the hall and worldwide, to broaden the reach of my delivery)

Learn how to get started with Twitter from these excellent videos from Rob Rogers and co at - expect more from them



Life Long Learning & Metacognition

More than anything else, FOAMed makes one think about HOW we learn in medicine. Osler nailed this “medicine is a science of uncertainty and an art of probability”. We like to think that we are astute diagnosticians – but we are constrained by our inherent cognitive bias.

Understanding HOW we make decisions is particularly important in critical care medicine – making decisions based on limited information, under pressure.

I recommend :

Simon Carley talks on ‘Guess or Gestalt’ regarding decision-making in EM (from #CEMExeter14 conference)

Chris Nickson on why ‘All Doctors are Jackasses’ (from #smacc2013 conference)

Joe Lex on why FOAMed is essential to medical education (includes discussion of pedagogy, andragogy and heutagogy)

as well as Lex on ‘from Hippcrates to Osler to FOAM’

…and Chris Edwards’ excellent talk on ‘May the FOAMed Be With You’

There are a few more videos on decision-making & education here :

Damian Roland on ‘Evaluating Education’

Victoria Brazil on ‘Evidence based education’

Cliff Reid on ‘Resuscitation Dogmalysis’

Simon Carley (again) on ‘Do Risk Factors Factor?’

…and yet again, Carley delivers ‘Wrestling with Risk’

…and again on ‘educational Leadership & Subversion’


Where to from here?

If you are inspired to create some GOOD medical education content and host as FOAMed, we’d love to hear from you

This post on blogging and blog basics is useful


Laursen et al, 2014: POCUS for respiratory presentations

Journal Club 009

Author: Matthew Hung
Chris Nickson

Laursen CB, Sloth E, Lassen AT, Christensen Rd, Lambrechtsen J, Madsen PH, Henriksen DP, Davidsen JR, Rasmussen F. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med. 2014 Aug;2(8):638-46. doi: 10.1016/S2213-2600(14)70135-3. Epub 2014 Jul 3. PubMed PMID: 24998674.


  • In patients admitted to the emergency department with respiratory symptoms and signs, does point-of-care ultrasonography (POCUS) of the heart, lungs, and deep veins, in addition to the usual initial diagnostic testing, improve the percentage of correct diagnoses 4 hours after admission?



  • Prospective, single centre, single-blinded randomised controlled trial


  • n=315 patients admitted to the medical emergency department (ED) at Odense University Hospital, Denmark, with respiratory symptoms and signs

Inclusion criteria

  • Respiratory rate > 20/min
  • Oxygen saturation <95%
  • On oxygen therapy
  • Dyspnoea,
  • Cough, or
  • Chest pain

Exclusion criteria

  • Permanent mental disability
  • Age younger than 18 years, or
  • POCUS not done within 1 h after the primary assessment


  • Intervention (n=158)
    • POCUS of the heart, lungs, and deep veins performed within 1 h after the primary clinical assessment in the ED, in addition to the standard initial diagnostic testing.
  • Control (n= 57)
    • Standard initial diagnostic tests, including blood samples, blood gases, electrocardiogram and chest radiography.


Primary endpoint

  • 88.0% (95% CI: 82.8-93) in the intervention group versus 63.7% (56.1-71.3) in the control group had correct presumptive diagnoses (p<0.0001).
  • The absolute effect was 24.3% (95% CI: 15.0 to 33.1).

Secondary endpoints

  • Appropriate treatment was initiated 4h after ED admission in a significantly larger percentage of patients in the intervention group than the control group (78% versus 56.7%, p value <0.0001)
  • No significant difference for the percentage of patients with correct presumptive diagnoses after the primary clinical assessment by an ED physician
  • No significant differences in
    • the number of patients transferred to the intensive care unit
    • the number of readmissions
    • length of hospital stay
    • hospital free days
    • in-hospital mortality
    • 30 days mortality
  • Slightly increased number of advanced diagnostic testing ordered for the intervention group during stay in the ED: 63 (6.6%) versus 34 (3.6%); but not during the hospital stay
  • No significant difference in the time to diagnostic or therapeutic thoracocentesis



  • Masked auditing of discharged patients’ hospital data was used to establish the final diagnoses and the appropriateness of the initial treatment. This was subjective and there was inter-auditor variability.
  • A single center study with one physician that did all the sonographic examinations
    • the results might not be applicable or reproducible to other EDs or physicians, especially given that ultrasonography findings are very operator dependent
  • Patients were enrolled according to the availability of the investigator/ultrasonographer, rather than consecutive
  • There were many more diagnoses made by the masked auditors than the actual number of patients
    • It is not clear whether all the diagnoses had contributed to the patients’ presenting symptoms and signs, or were associated findings only, e.g. pleural effusion, pericardial effusion, systolic & diastolic failures, and parapneumonic effusion
  • Anaemia and malignancy were included in the auditor’s diagnoses, for anaemia in particular it is unclear how this is diagnosed by POCUS
  • It is possible that diagnostic accuracy might improve when a physician is prompted to reconsider the diagnosis by another physician, irrespective of whether the other physician has perfomed POCUS
  • Although there was increased additional investigation in the ED, this was not significantly different over the course of the hospital stay – suggesting that POCUS may lead to more rapid further investigation.
  • Despite the increased percentage of patients who were given a correct presumptive diagnosis and appropriate early treatment, no difference was noted in patients’ morbidity and mortality outcomes. In fact, concerningly, there was a trend in the opposite direction. However, this study was not powered to detect improvements in mortality or morbidity.
  • The authors recommended that POCUS of the heart, lungs, and deep veins in patients with respiratory symptoms should be implemented in ED, however it is questionable whether their own data supports this conclusion. Although the study suggests POCUS leads to more accurate diagnoses, clinical outcomes were not improved and questions are raised about cost-effectiveness. Could an increased ability to find disease mean more testing and more harm? (e.g. ‘incidentalomas’)


POCUS in the emergency department, in the hands of a skilled practitioner, may lead to more accurate diagnosis in patients with respiratory presentations. This finding is not necessarily applicable to other settings and may not improve patient outcomes.

The post Laursen et al, 2014: POCUS for respiratory presentations appeared first on INTENSIVE.

#FOAMed Review 12th Edition

Welcome to the twelfth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMexplore which allows you to view previous #FOAMed review by edition or by selecting from CORD curriculum categories.

Onto the FOAMed.

LAMOTRIGINE IS KETAMINES BLACK SWAN [BLOG]: Interesting post on case report (and there are several others) on failure of ketamine sedation in lamotrigine overdose from Sydney HEMS. 

EVIDENCE FOR MIDLINE CATHETER INSERTION [BLOG]: Should we be optimizing our US guided peripheral venous cannulations with midline catheters instead of the usual equipment. Excellent case made by EM Nerd in his post, 'The Adventure of the Sussex Vampire.'

HYPERTROPHIC CARDIOMYOPATHY ON ECHO [BLOG]: A few evidence based tips and tricks to recognizing HCM on beside echo at Champagne Tap.

THE FALLACY OF HALOPERIDOL ALLERGY [BLOG]: "There are no reports of anaphylaxis, angioedema or cutaneous allergy from haloperidol." This explanation and more at Pulm Crit. 

More FOAMed.


PERIPHERAL VASCULAR INJURY [BLOG]: Excellent and succinct review on diagnosis and management of traumatic peripheral vascular injury at EM Docs. 


HAND FOAMED [PODCAST]: How to perform a good hand neuro exam, Kanavel's signs for flexor tenosynovitis, finger amputations and more in this well versed podcast at Foamcast. 

ECG Interpretation 

The 360 Degree Heart  [BLOG]: Do you truly understand the hexaxial reference system? Highly recommended graphical representation and explanation of how the 12-lead ECG maps onto the hexaxial reference system. This is helpful with the concept of axis and reciprocal depressions in STEMI. Thank you EMS 12-lead. 

Thoracic & Respiratory Disorders 

CROUP [BLOG]: Wise words about managing the little one's that present to your ED with a barking cough, stridor and subcostal retractions at Don't Forget the Bubbles.


See you next week. 

#FOAMed review is brought to you by Michael Macias. If you want to recommend content you think should be added to our curriculum, send me an email, I would love to hear from you. 


Lombalgia e cortisone, la storia continua

In medicina, come nella vita, i corsi e i ricorsi storici si rincorrono.Farmaci o procedure prima esaltati poi messi in soffitta e poi nuovamente alla ribalta, grazie a nuovi studi. Questo il preambolo doveroso su un tema che molti riterranno desueto e persino noioso, ma che richiama grande interesse, soprattutto da parte dei pazienti, visto […]

The post Lombalgia e cortisone, la storia continua appeared first on EM Pills.